c. ECG for dysrhythmias.
d. patient response to electrolyte replacement therapy.
e. loss of electrolyte-rich body fluids, such as nasogastric suc-tioning, ileostomy drainage, diarrhea, wound drainage, or diaphoresis.
f. side effects of prescribed electrolyte supplements.
g. intake and output and possibly daily weights.
h. signs of tetany
i. signs of CNS depression
4. Administer supplemental electrolytes as indicated.
5. Closely monitor serum potassium levels in patients taking diuretics with digoxin.
6. Medicate for pain as needed.
7. Obtain ordered specimens for laboratory analysis of serum and urine electrolytes and ABGs as indicated.
8. Maintain I.V. solution containing electrolytes at a constant flow rate.
9. Provide a safe environment for patients with neurologic and neu-romuscular manifestations of electrolyte imbalances.
10. Use an infusion pump when administering parenteral potassium and magnesium.
11. Incorporate seizure precautions into nursing care when indicated.
12. Encourage compliance with therapeutic regimen.
13. Maintain patent I.V. line.
Sources: Sparks & Taylor (1998), Hogan & Wane (2003).
Provide written material and verbal instructions regarding any medications.
Provide information on predisposing factors associated with specific elec-trolyte imbalances.
Review indicators of digitalis toxicity, if appropriate.
Provide information on dietary sources of electrolytes in deficit situations when appropriate.
Educate regarding salt substitutes, potassium-sparing diuretics, and other predisposing drugs.
Provide information on over-the-counter medications (e.g., magnesium and aluminum hydroxide, antacids and phosphorus-binding antacids, laxa-tives, multivitamin and mineral supplements) when appropriate.
Educate the patient with cancer about symptoms of hypercalcemia.
Patient Education
(Continued on following page)
Educate the patient about appropriate use of laxatives if deficit is caused by abuse.
Educate the patient on the high phosphorus content of processed foods, carbonated beverages, and over-the-counter medications when appropriate.
Patients’ disease states that might require home electrolyte replacement ther-apy include:
■ Cardiopulmonary disorders: potassium replacement.
■ Gastrointestinal disorder: intractable diarrhea, hyperemesis gravi-darum
■ Patients receiving chemotherapy
■ Electrolyte replacement therapies usually last from 1 to 7 days. The elec-trolytes are provided through a peripheral indwelling venous access device unless a long-term access device is available.
■ Assess patients taking oral electrolyte supplements for compliance.
■ The seven major electrolytes and their symbols are:
■ Cations:
■ Sodium: Na⫹
■ Potassium: K⫹
■ Calcium: Ca2⫹
■ Magnesium: Mg2⫹
■ Anions:
■ Chloride: Cl
-■ Phosphate: HPO4
-■ Bicarbonate: HCO3
-■ The prefix hypo: Deficit in an electrolyte
■ The prefix hyper: Excess in an electrolyte
■ Key nursing interventions for electrolyte imbalances:
■ Monitor laboratory values
■ Frequent assessments of neurologic, cardiovascular respiratory, GI, integumentary status; special senses; body weight; and vital signs
■ Monitor ECG.
■ Monitor for phlebitis.
■ Monitor for symptoms of fluid overload.
■ Accurate intake and output
Home Care Issues
Key Points
■ Safety precautions when the patient is confused
■ Patients taking digitalis need to be monitored carefully for digoxin toxicity.
■ Monitor arterial blood gases when appropriate.
■ Key laboratory values that the nurse must recognize:
■ Potassium K⫹3.5 to 5.5 mEq/L
■ Calcium: Na⫹135 to 145 mEq/L
■ Magnesium (Mg2⫹) 1.5 to 2.5 mEq/L
■ Phosphate (HPO4-) 3.0 to 4.5 mg/dL
■ Chloride (Cl-) 95 to 108 mEq/L
■ Critical guidelines for infusion potassium include:
■ Never give potassium I.V. push.
■ Concentrations of potassium greater than 60 mEq should not be given in a peripheral vein.
■ Concentrations greater than 8 mEq/100 mL can cause pain and irri-tation of peripheral veins, leading to phlebitis.
■ Do not add potassium to a hanging container.
■ Administer potassium at a rate not exceeding 10 mEq/h through peripheral veins.
■ Calcium and phosphate have a reciprocal relationship: When one is ele-vated, the other is decreased.
■ Patients with calcium imbalances may need seizure precautions.
■ Monitor for calcemia in patients receiving massive transfusions of cit-rated blood.
■ Trousseau’s sign and Chvostek’s sign are specific for calcium deficit.
■ Patients with calcium excess (i.e., hypercalcemia) need to be treated with saline diuresis and may need hemodialysis.
■ The most dangerous symptom of hypocalcemia is laryngospasm.
■ The four major acid–base imbalances in the body are respiratory acido-sis (carbonic acid excess), respiratory alkaloacido-sis (carbonic acid deficit), metabolic acidosis (base bicarbonate deficit), and metabolic alkalosis (bicarbonate excess).
■ Acid–base balance is maintained through three major reaction-specific buffer systems that regulate hydrogen ion concentration: the carbonic acid–bicarbonate system, the phosphate buffer system, and the protein buffer system.
■■ Critical Thinking: Case Study
A 65-year-old man presented to the emergency room with complaints of chronic tiredness and increased skin pigmentation. On examination his blood pressure was low: 98/60 mm Hg. Blood test revealed a plasma potas-sium level of 6.8 mEq/L and a plasma sodium level of 132 mEq/L. The BUN was 20 mg/dL and the serum creatinine was 1.2 mg/dL
What is the electrolyte imbalance? What is the underlying cause? What nursing diagnoses would apply to this patient? What would be the treat-ment options for this patient?
Media Link: Use the enclosed CD–ROM for more critical thinking activities and the answers to this case study.
Post-Test
In questions 1 through 8, match the signs and symptoms in Column I to the clinical manifestation in Column II.
Column I Column II
1. CNS depression, drowsiness, lethargy 2. Hyperirritability, tremors, increased
tendon reflexes
3. Carpopedal spasm, laryngeal spasm, convulsions
4. Bone tumors, prolonged immobilization, increased PTH secretion
5. Fatigue, headache, apprehension, serum Na⫹115
6. Serum Na⫹150, urine Na⫹less than 40 mEq/L, urine specific gravity greater than 1.125
7. ECG with flat or inverted T wave, depressed ST segment
8. ECG with peaked, narrow T wave, shortened QT interval, prolonged PR interval followed by disappearance of P wave
9. Treatment for a patient with metabolic alkalosis includes:
a. Removal of underlying cause b. I.V. fluid administration with NaCl
c. Replacement of potassium deficit d. All of the above
10. To correct metabolic acidosis, the parenteral fluid of choice is:
a. NaHCO3 b. NaCl
a. Hypomagnesemia b. Hypermagnesemia c. Hypocalcemia d. Hypercalcemia e. Hypernatremia f. Hyponatremia
g. Hypokalemia h. Hyperkalemia
c. Albumin
d. 5 Percent dextrose in water 11. The pH range of arterial blood is:
a. 7.25 to 7.35 b. 7.35 to 7.45 c. 7.45 to 7.55 d. 7.56 to 8.05
12. A nursing diagnosis that would be appropriate for the patient with calcium deficit would be:
a. Ineffective breathing pattern related to biochemical im-balances
b. Altered comfort related to injuring agent
c. Risk for injury related to electrolyte imbalance, tetany, and seizures
d. Altered urinary elimination pattern related to changes in renal function
Media Link:Use the enclosed CD–ROM with this text for more practice test questions and answers along with rationales.
References
Hogan, M.A., & Wane, D. (2003). Fluids, Electrolytes and Acid Base Balance. Upper Saddle River, NJ: Prentice–Hall.
Horne, C., & Derrico, D. (1999). Mastering ABGs. American Journal of Nursing, 99(8), 26–33.
Lee, C.A., Barrett, C.A., & Ignatavicius, D. (1996). Fluids and Electrolytes (4th ed.).
Philadelphia: F.A. Davis.
Metheny, N.M. (2000). Fluids and Electrolyte Balance. In Metheny N.M. (ed.).
Nursing Considerations (4th ed.). Philadelphia: Lippincott-Williams & Wilkins, pp. 59–181.
National Student Nurses’ Association (1997). Specific Electrolyte Imbalances. In McEntee, M.A., & Gil, G.M. (eds.). Fluids and Electrolytes. Albany, NY: Delmar, pp. 36–70.
Narins, R. (1994). Clinical Disorders of Fluid and Electrolyte Metabolism (5th ed.).
New York: McGraw–Hill, p. 282
Phillips, L.D., & Kuhn, M. (1999). Manual of IV Medications (2nd ed.). Philadelphia:
Lippincott.
Sparks, S.M., & Taylor, C.M. (1998). Nursing Diagnosis Reference Manual (4th ed.).
Springhouse, PA: Springhouse Corporation.
Weldy, N.J. (1996). Body Fluids and Electrolytes. A Programmed Presentation (7th ed.).
St. Louis: Mosby, pp. 83–119, 127.